Laserfiche WebLink
e. ❑ Other Federal AgencylCode ( i <br />16. Source or Contact (Name, Location, Affiliation, Telephone Number) <br />Referral 17. a. Safety <br />Classification.. <br />(1) ❑ Imminent Danger (2) ❑ Serious (3jOther <br />16. 13 Migrant Farmworker Camp <br />19. Hazard Description <br />R..--.cam. a <br />0 <br />?.sg -131' I1 <br />b. Health <br />(1) D Imminent Danger <br />(2) D Serious <br />I <br />1- —al b. Date Letter Sent: c. Date Response Due: <br />Action 20. a- D Send Letter <br />22. Inspection Planned? If Yes, If No, <br />❑ Yes ❑ No Priority: Reason - <br />23. Transfer to (Name): <br />25. Transfer to (Category); <br />a. ❑ Federal OSHA/Reporting ID <br />b. D State OSH/Reporting ID 9506 R ❑ D ❑ <br />26. Optional Information <br />21. Supervisor(s) Assigned <br />a. I b. <br />24. Transfer Date: <br />a D Other Federal Agency/Code ( ' <br />d. ❑ StatelLDcal Government <br />e. ❑ Other <br />Type <br />ID <br />Value <br />Type <br />ID <br />TATE <br />STATE <br />Referral <br />Report Y- <br />OF CALIFORNIA <br />IFORNIA <br />DrPARTt (OF IfJ <br />QIV <br />AL RELATIONS <br />OF OCCUPATIONAL SAF=TY ARID HEALTH <br />MOD Date <br />(t. Reporting !D_ <br />R <br />I2. Previous Activity? <br />tf Yes, ❑ Yes <br />! IJo <br />13. Referral IJumber <br />(Relerrral s this <br />____j27. <br />Total <br />Entries <br />4�J I <br />9506 i <br />Enter Type: Number. <br />a. ❑ <br />Change?5. <br />b taolisnment fame <br />Employer ID (State's option) <br />6 a ❑ <br />Change? <br />`" g <br />o Site Ad ess (Street, City, Stat Zip) 1 <br />�/ • <br />zrt�z (� �E <br />A Q <br />Z City Code 8. County Code <br />. 1GSEJ�� 1 1 <br />9. Malting Address (Stye t, City, State, ZIP) <br />h 15331 �.OiO �7 <br />Industry & <br />Ownership <br />10. 4P. of Business <br />L T <br />J <br />11. Prima SIC <br />R` <br />12. No. of employees <br />; <br />- <br />`I Sal )L <br />5 <br />13. Ow ship (Mark "X," in one box.) <br />a. Private Sector b- ❑ Local Government c. <br />D State Government d. D Federal Agency/Code ) <br />Source <br />14. Referred By: <br />15. Date Received _ <br />a. D CSE/IH (Within office)/CSE/IH ID I <br />i. ❑ Consultation <br />b. 11 Federal OSHA <br />g. D StatelLocal Government <br />C. State bSH <br />h. ❑ Media <br />d. ❑ Discrimination <br />i. 'El Other (specify) <br />e. ❑ Other Federal AgencylCode ( i <br />16. Source or Contact (Name, Location, Affiliation, Telephone Number) <br />Referral 17. a. Safety <br />Classification.. <br />(1) ❑ Imminent Danger (2) ❑ Serious (3jOther <br />16. 13 Migrant Farmworker Camp <br />19. Hazard Description <br />R..--.cam. a <br />0 <br />?.sg -131' I1 <br />b. Health <br />(1) D Imminent Danger <br />(2) D Serious <br />I <br />1- —al b. Date Letter Sent: c. Date Response Due: <br />Action 20. a- D Send Letter <br />22. Inspection Planned? If Yes, If No, <br />❑ Yes ❑ No Priority: Reason - <br />23. Transfer to (Name): <br />25. Transfer to (Category); <br />a. ❑ Federal OSHA/Reporting ID <br />b. D State OSH/Reporting ID 9506 R ❑ D ❑ <br />26. Optional Information <br />21. Supervisor(s) Assigned <br />a. I b. <br />24. Transfer Date: <br />a D Other Federal Agency/Code ( ' <br />d. ❑ StatelLDcal Government <br />e. ❑ Other <br />Type <br />ID <br />Value <br />Type <br />ID <br />Value <br />)u r•,...._.__._. <br />____j27. <br />Total <br />Entries <br />CALOSH-90 (IW89) <br />